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Tinea Capitis Treatment Wrestling with Rashes Sports Medicine Conference August 5, 2019 Brandon D. Newell, MD Pediatric Dermatologist Assoc. Prof. of Pediatrics UMKC © The Children's Mercy Hospital, 2017 Disclaimers . No financial disclosures . Will be discussing off-label uses of medications and treatments 2 Wet Hands . 14 yo female . Several year history of sweaty hands and feet . Worse when nervous, scared, hot . Constantly wipes hands on pants and towels . Having trouble at school: messes up written paperwork, embarrassed, trouble using touch screen electronic devices . Hands “slip” when playing basketball or gymnastics because they are wet 3 4 5 Hyperhydrosis . Idiopathic hyperhidrosis, aka primary pediatric hyperhidrosis . Excessive production of sweat in response to heat/emotional stimuli/other stimuli . Hands, feet, axilla, body . Not drug related, not metabolic related (does not happen when asleep) . Mild Severe . Severe: disabling, embarrassing, interfere with work/play/sports, affect social interactions 6 Hyperhydrosis Treatment Topical : qHS- BID Oral • 12% aluminum chloride . Glycopyrolate (OTC): Certain Dri Roll On . 1-3mg BID • 20% aluminum chloride . SE: dry mouth, blurry (Drysol) vision, constipation, tachycardia • Qbrexza (glycopronnium) . Start low, titrate up cloths (available Oct. 2018) AS Paller, et al.: Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis. 7 JAAD. 67:918-923 2012. www.sweathelp.org 8 Tapwater iontophoresis – Electric device that delivers a direct current to patient – Uses Tap Water as the conductive medium – MOA? Causes development of keratotic plugs in the eccrine sweat ducts – Effect may last for weeks – Iontophoresis units (Drionic, General Medical Co., Los Angeles, CA) are available without a prescription via mail or internet (www.drionic.com) 9 10 Tinea “The Fungus” . Dermatophytes are fungi that use keratin for growth . Infect keratin-containing body parts: . Hair: tinea capitis . Skin: tinea corporis (face: tinea faciei) . Nails: tinea unguium (onychomycosis) . 3 major reservoirs: . Humans (anthropophilic) . Animals (zoophilic) . Soil (geophilic) Types of Tinea capitis infections . Endothrix . Most commonly caused by Trichophyton tonsurans and other T. spp. Hyphae grow down hair follicle/penetrate hair shaft . Does not fluoresce . Most common in U.S. Weston, Lane: Textbook of Pediatric Dermatology, 1996 Types of Tinea capitis infections . Ectothrix . Frequently caused by Microsporum spp. M. canis, M. audouinii, M. gypseum . Hyphae invade hair shaft, but then grow out of the follicle and cover the hair shaft . Does fluoresce M. Canis Scarring Tinea Capitis Treatment . Culture: takes 2 weeks to grow . Oral Antifungal: Oral Griseofulvin or Terbinafine (Lamisil) for 6-8 weeks . Antifungal shampoo to reduce transmission . 1-2% Ketoconazole (Nizoral AD, Nizoral Rx ) . 2.5% Selenium sulfide (Selsun Blue) . 1-2% Zinc pyrithione (Head and Shoulders) 20 21 22 Tinea Corporis treatment . Topical Antifungal (OTC or Rx): x 2 weeks – OTC Lamisil cream (generic Terbinafine), Lotrimin Ultra – RX: Ketoconazole cream, Econazole cream, Naftin cream SEVERE CASES MAY REQUIRE ORAL THERAPY PREVENTATIVE?: Use antifungal shampoo as a body wash daily, esp after practices OTC Nizoral AD shampoo (1% Ketoconazole) Soak feet in dilute white vinegar (1:1 with water) BID, wash/dry clothing/shoes, OTC Lamisil spray in shoes and Vinegar spray equipment weekly Alter SJ, et al. Common Child and Adolescent Cutaneous Infestations and Fungal Infections .Curr Probl Pediatr Adolesc Health Care. 2018 Jan;48(1):3-25. doi: 10.1016/j.cppeds.2017.11.001. Epub 2017 Dec 6. Molluscum Contagiousum . Not a spell from Harry Potter . Caused by a DNA pox virus . Spread from skin contact . Common in children, less common in adolescent, rare in adults 24 Molluscum Contagiousum . Lesions have white cores . Develop a dermatitis around them=itchy . Lesions get red inflamed/appear infected before they resolve . Infections can take months to years to resolve . Can cause small pitted scarring 25 26 27 Molluscum Treatment . No treatment – months to years . Topical cantharone (Blister beetle extract)-FDA import ban . Liquid nitrogen . Curettage (Topical lidocaine cream/cut them off) – painful/scarring/bleeding . Oral Cimetidine (Tagamet) x 3 month . Prevention: Regular bathing & handwashing, don’t reuse towels/washcloths, moisturizer Forbat E, et al.. Molluscum Contagiosum: Review and Update on Management. Pediatr Dermatol. 2017 Sep;34(5):504-515. doi: 10.1111/pde.13228 28 29 Herpes Simplex . Common viral infection of the skin . HSV 1: cold sores, fever blisters, skin lesions . HSV 2: genital ulcers, can cause skin and lip lesions . Spread through physical contact: skin, fomites 30 31 32 Herpes Gladiatorum 33 34 HSV Treatment . Topical: not very effective – OTC Abreva – Rx Acyclovir ointment . Oral: – Acyclovir (Zovirax), Valcyclovir (Valtrex), Famciclovir (Famvir) – treatment and prophylaxis . IV: Acyclovir Peterson AR, et al. Infectious Disease in Contact Sports. Sports Health. 2019 Jan/Feb;11(1):47-58. doi: 10.1177/1941738118789954. Epub 2018 Aug 14. 35 HSV Prevention . Moisturizer – improves skin barrier . Sunscreen – sunlight reactivates the virus . Avoid skin to skin contact, clean headgear . Treat at first sign of symptoms – “before the outbreak” . Some require prophylaxis for the season/year-round 36 37 38 39 40 Examine under microsope Clinical Pediatric Dermatology, 2016 41 Tinea Versicolor . Aka - pityriasis versicolor . Dimorphic fungus (yeast form): known as Malassezia furfur, aka . Common superficial fungal Pityrosporum orbiculare or ovale. disorder of the skin . Yeast produces a dicarboxylic acid . Multiple scaling, oval macules, called Azelaic acid, this blocks patches, and thin plaques dopa-tyrosinase reaction = causes . Trunk, upper arms, neck or face hypopigmentation in dark (sebum “rich” areas) skinned individuals 42 43 44 45 Tinea versicolor: . DDx: CARP, Retention . Treatment: hyperkeratosis, vitiligo, . Topical – variety of tinea corporis, allergic options, hard for large contact dermatitis, surface areas postinflammatory hyperpigmentation . Oral – easier, more costly 46 Tinea Versicolor Treatment . Topical . Oral . Selenium sulfide shampoo . Ketoconazole: 400mg + exercise: FDA daily x 1-2 weeks warning about liver toxicity (87.9% success) . Itraconazole: 400mg x1=200mg qd x1 . Ketoconazole shampoo or week (drug interactions, liver toxicity, CHF) cream daily x 1-2 weeks . Fluconazole: 300mg once, repeat in . Terbinafine spray x 2 1-2 weeks (81.5% success) weeks Hu SW, M Bigby: Pityriasis versicolor: a systematic review of interventions. Arch Dermatol. 146 (10):1132-1140 2010 MJ Yazdanpanah, H Azizi, B Suizi: Comparison between fluconazole and ketoconazole effectivity in the47 treatment of pityriasis versicolor. Mycoses. 50:311-313 2007 .
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